Pediatric Health History
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PATIENT’S INFORMATION LAST NAME FIRST NAME MIDDLE INITIAL NICKNAME
SOCIAL SECURITY NUMBER BIRTHDATE SEX PATIENT’S MOTHER’S MAIDEN NAME MALE FEMALE PATIENT’S BILLING/MAILING ADDRESS PATIENT’S PHYSICAL ADDRESS (if different from billing/mailing address) STREET OR PO BOX STREET ADDRESS
CITY STATE ZIP CITY STATE ZIP
PATIENT’S CONTACT INFORMATION MOBILE PHONE # DAY PHONE # ALTERNATE PHONE # E-MAIL ADDRESS
Preferred Method for Notifications (check all that apply): Phone Text E-mail Automated Recordings PATIENT’S EMERGENCY CONTACT INFORMATION NAME ADDRESS RELATIONSHIP CONTACT PHONE NUMBER
PATIENT’S ADDITIONAL INFORMATION – For Purposes of Grant Funding
RACE (you may mark more than one) ARE YOU OF HISPANIC OR LATINO ORIGIN? PRIMARY LANGUAGE ENGLISH AMERICAN SPANISH INDIAN/ALASKAN NATIVE YES OTHER ASIAN NO ______ BLACK/AFRICAN AMERICAN NATIVE HAWAIIAN ARE YOU A VETERAN OF THE U.S. OTHER PACIFIC ARMED FORCES? ISLANDER WHITE YES NO
1. In the last two years, have you or a member of your family MARITAL STATUS HOUSEHOLD SIZE ESTIMATED worked in fields, orchards, greenhouses, farms, vineyards, packing SINGLE □ 1 □ 6 HOUSEHOLD houses, or with animals, such as cattle, dairy, sheep, poultry, fish MARRIED □ 2 □ 7 INCOME hatcheries, etc.? DIVORCED □ 3 □ 8 YES NO WIDOW $ □ 4 □ 9 2. In the last two years, have you or your family moved to another LE □ 5 □ 10 GALLY WEEarea to work in fields, orchards, greenhouses, farms, vineyards, SEPARATED KLY packing houses, or with animals, such as cattle, dairy, sheep, □ OTHER poultry, fish hatcheries, etc.? LIFE BI- YES NO PARTNER WEEKLY OTHER MON THLY ANN UALLY HOUSING STATUS
□ CURRENT RESIDENT OF PUBLIC HOUSING □ HOMELESS Doubling Up Shelter Transitional Unknown/Other □ NOT HOMELESS AND NOT CURRENT RESIDENT OF PUBLIC HOUSING RESPONSIBLE PARTY’S INFORMATION (if different than patient) NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME
SSN BIRTHDATE SEX RELATIONSHIP TO PATIENT
RESPONSIBLE PARTY’S BILLING/MAILING ADDRESS (if different than patient) STREET OR PO BOX
CITY STATE ZIP HOME PHONE NUMBER PATIENT’S EMPLOYER NAME OF EMPLOYER: LOCAL ADDRESS CORPORATE ADDRESS EMPLOYER’S ADDRESS (Street, City, State and Zip) COUNTY
TYPE OF BUSINESS OCCUPATION
EMPLOYMENT STATUS WORK PHONE #:
FULL-TIME PART-TIME RETIRED DISABLED
PRIMARY INSURANCE
TYPE OF PRIMARY COVERAGE: MEDI-CAL MEDICARE PRIVATE INSURANCE NONE OTHER NAME OF INSURANCE COMPANY POLICY NUMBER GROUP NUMBER
ADDRESS OF INSURANCE COMPANY (Street, City, State, and Zip) EFFECTIVE DATE EXPIRATION DATE
SECONDARY INSURANCE (if applicable) NAME OF INSURANCE COMPANY POLICY NUMBER GROUP NUMBER
ADDRESS OF INSURANCE COMPANY (Street, City, State, and Zip) EFFECTIVE DATE EXPIRATION DATE
CONSENT FOR TREATMENT
I, the undersigned, certify that the information contained on this form is correct to the best of my knowledge. Furthermore, I authorize the release of any medical information necessary to process the claim for treatment, payment, or operations. I authorize payment of medical benefits to My Family Clinic, provider or suppliers for services. I hereby authorize the provider and whomever else he/she may designate as his/her assistant(s), to administer those treatments and procedures which in his/her opinion are deemed necessary. I hereby agree, regardless of insurance coverage, that I am responsible for all charges incurred. Payment is expected at the time of service. We will bill your insurance as a courtesy. I provide my consent for My Family Clinic to share relevant medial information with the California Immunization Registry (CAIR) and its partners.
Patient or Guardian’s Signature (if under 18) Date
Responsible Party’s Signature Date
Witness
Household Member Name DOB MRN UDS Status Updated* PEDIATRIC HEALTH HISTORY
(Ages 0-18 years)
Name Date of Birth (Month/day/year)
I. ANSWER THE FOLLOWING QUESTIONS (Check Yes or No and fill in the blanks):
# N Questions o
1 Where was your child born?
2 Were there any problems during your pregnancy? If yes, explain:
3 Was your delivery Vaginal or C-Section? Was there any problems? If yes, explain:
4 Was your child born premature? If yes, were there any problems?
5 What was your child’s birth weight? Birth length?
6 Does your child have a primary care physician? Who? Date of last exam:
7 Does your child have a dentist? Who? Date of last exam:
8 Is your child currently taking any medications? List:
9 Has your child ever been hospitalized? Why? Where?
10 Has your child had any serious injuries? When? Where?
11 Has your child had any surgeries? When? Where?
12 Does your child have any allergies to medications?
13 Does your child have any allergies to food, Asthma, Hives, Eczema, or Hay Fever? Other II. HAS YOUR CHILD HAD OR CURRENTLY HAVE HAD ANY OF THE FOLLOWING? (Check Yes or No):
# N Questions # Yes No Questions o
14 Problems walking 22 Nursed as an infant? How long?
15 Problems toilet training 23 Problems with diet
16 Problems with colic 24 Use/d any special diets
17 Problems in school 25 Attended a special school or classes
18 Problems with sleeping 26 Nightmares
19 Problems with bedwetting 27 Discipline or behavior problems
20 Problems with nail biting 28 Ever seen a Psychologist
21 Problems with weight/height 29 Speech Therapist or Speech teacher III. FOR FEMALES ONLY (Check Yes or No): # N Questions # Yes No Questions o
Does your child have difficult menstrual 30 32 Is your child taking birth control? periods? 31 At what age did your child start her first 33 Has your child had a miscarriage or abortion? period?
IV. HAS YOUR CHILD HAD OR CURRENTLY HAVE ANY OF THE FOLLOWING PROBLEMS? (Check Yes or No):
# Yes No Questions # Yes No Questions
34 Head 40 Kidney/bladder
35 Eyes 41 Lungs/asthma/bronchitis/pneumonia
36 Ears/nose/throat 42 Bones/muscles/joints 37 Heart/murmur/high blood pressure 43 Anemia 38 Stomach/constipation 44 Skin/rashes 39 Wear glasses or contacts? 45 Wear dental bridges/plates/braces? V. HAS YOUR CHILD HAD OR CURRENTLY HAVE ANY OF THE FOLLOWING PROBLEMS? (Check Yes or No): # Yes No Questions # Yes No Questions 46 Hepatitis 49 Diabetes 47 Chickenpox 50 Had a Seizure 48 Dizzy or passed out during or after exercise? 51 Been unconscious/had a concussion VI. FAMILY HISTORY (Check Yes or No and fill in the blanks):
# Yes No Questions # Yes No Questions
52 Father health problems 54 Brothers/sisters How many:
53 Mother health problems 55 Brothers/sisters health problems
VII. ANY FAMILY HISTORY OF? (Check Yes or No and fill in the blanks):
# Yes No Questions # Yes No Questions
56 Diabetes 60 Convulsions
57 Allergies 61 Heart Disease
58 TB 62 Cancer
59 A.I.D.S/HIV 63 Hepatitis
VIII. OTHER INFORMATION (Check Yes or No and fill in the blanks):
# Yes No Questions
64 Are you or your children exposed to domestic abuse/violence?
65 Does your child have any other diseases or medical conditions NOT listed on this form? If so, please explain:
66 What is your child’s last primary care doctors address: 67 Where did your child live before coming to this area? When did you move here?
68 Is your child able to perform activities of daily living (ADL)? If no, please explain:
69 Any special comments about your child?
70 Do you have any religious, cultural, physical, or other factors that might influence your care? If so, please list:
To the best of my knowledge, I have answered every question completely and accurately. I will inform my provider of any change in my health or medications. Patient or Guardian’s Signature (if under 18) Date Notice of Privacy Practices
We are committed to protecting your personal health information in compliance with the Federal law. We may use or disclose your personal health information for these purposes:
For Treatment, Payment, Health Care Operations, Appointment Reminders, Health Related Services and Treatment Alternatives, Fundraising Activities, Individuals Involved in Your Care or Payment for Your Care, Research, Organ and Tissue Donation, As Required By Law, To Avert a Serious Threat to Health or Safety, Military and Veterans, Workers’ Compensation, Public Health Activities, Health Oversight Activities, Lawsuits and Disputes, Law Enforcement, Coroners, Health Examiners and Funeral Directors., National Security and Intelligence Activities. Protective Services for the President and Others, and Inmates.
You have certain rights with respect to your personal health information:
Right to Inspect and Request a Copy, Right to Amend, Right to Receive an Accounting of Disclosures, Right to Request Restrictions, Right to Receive Confidential Communications, Right to a Paper Copy of this Notice.
Changes to this Notice:
We reserve the right to change this notice and to make the changed notice effective for all of the health information that we maintain about you, whether it is information that we previously received about you or information we may receive about you in the future. We will have available a copy of our current notice in our facility. Our notice will indicate the effective date on the first page, in the center of page. We will also give you a copy of our current notice upon request.
Complaints:
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You may file a complaint by mailing us a written description of your complaint or by telling us about your complaint in person or over the telephone:
Maria Rodriguez, Office Manager My Family Clinic 81709 Dr. Carreon Blvd. Suite C5 Indio, CA 92201 (760) 342-4200 ACKNOWLEDGEMENT OF RECEIPT PRIVACY PRACTICES NOTICE AND ADVANCE HEALTH CARE DIRECTIVES INFORMATION
RECONOCIMIENTO DE RECIBO DEL AVISO DE LAS PRÁCTICAS DE PRIVACIDAD Y DIRECTIVAS POR ANTICIPADO SOBRE LA ATENCIÓN DE LA SALUD
I, have received a copy of My Family Clinic Privacy Practices Notice and Advance Health Care Directives information.
Patient’s Signature Date
Signature of Parent or Patient’s Representative Date
Yo, reconozco que he recibido una copia del Aviso de las Prácticas de Privacidad y Directivas por Anticipado sobre la Atención de la Clínica de Mi Familia.
Firma del Paciente Fecha
Firma del padre del paciente o algún representante Fecha
Patient Name DOB: MR #
Receipt of hipaa advanced directives Tab - 06/17 Authorization/Consent IMMUNIZATION SERVICES RECORD OF CONSENT 1. I agree that the person named below will receive vaccine(s) suggested by the Physician. 2. I will receive a copy of the Vaccine Information Statement (VIS) after every immunization. 3. The benefits and risks of the vaccine to be administered will be explained before every vaccine. 4. I have the right to ask questions about the disease, the vaccine, and how the vaccine is given. 5. I am a parent or legal guardian who can legally consent for that person named below to get the vaccine(s). I freely and voluntarily give my signed permission for each vaccine. Consent for the California Automated Immunization Registry (CAIR) I authorize the California Automated Immunization Registry to release immunization records only, if needed, on my child to any of the following; a. Local Health Department b. A physician requesting Immunization record c. School in which the child is enrolled d. Child Care Facility in which the child is enrolled. INFORMATION about the person to receive vaccine:
Last Name MI First Name
Date of Birth: Male Female
Street Address: Phone #
City State Zip Code Mother’s First Name (required)
Other family member(s) given permission to bring child in for immunizations: Name Relationship to child
Name Relationship to child
Please circle the category which best describes the child’s payment status
1. CHDP/Cen-Cal # 4. Insurance does not cover IZ
2. Without Insurance 5. Not Eligible (ex: Healthy Families, BX, BS) 3. Am. Indian/Native Alaskan
Signature of Patient / Parent or Guardian Relationship to child Date
CAIR # Medical Record # Disclosing Staff: 81709 Dr. Carreon Blvd suite C- Indio CA 92201 Phone: (760) 342-4200 Fax: (760)-342-1600
PEDIATRIC INSURANCE PATIENT ELIGIBILITY WAIVE
PLEASE NOTE: This form must be completed and signed each time your child is seen in our office and eligibility cannot be confirm on the date of service. This includes new born children as well as existing patients who appointment was not booked in advance, as we may not have time to verify current eligibility.
PATIENT NAME: ______D.O.B ___/___/____
NAME OF THE INSURANCE: ______
My child, ______, is currently enrolled with ______
______, (Name of the Insurance)
And his/her coverage began ______(Date of eligibility)
I, ______(Parent or Guardian), understand that if my child’s eligibility has not been established within the next 60 days, I or the person financially responsible for my child will assume full responsibility for all charges incurred. In the case of a newborn child in process of being enrolled in an HMO Plan, I agree to immediately notify the insurance company of my request to assign the child to Dr. H. David Sacks, DO as their Primary Care Provider (PCP). If my child is not assigned to Dr. H. David Sacks retroactive to the first date he/she was seen in the office, I will be responsible for payment of all charges incurred prior the effective date of the PCP assignment (Unless my insurance Company pays for the visit (s) as a “fee for service visit”). In the case of existing patients whose eligibility & benefits have not been re-confirmed on the date of service, I agree to pay in full any charges that are dined by my insurance company
I agree that if the insurance information is not correct, I (or the person financially responsible for my child) will pay in full as such charges. I also understand that any additional co-pay that applies to such visit will be billed to me, and that I am responsible for paying such co-pay.
______(Subscriber’s name PRINTED)
______(Parent or Guardian Signature)
______(Social Security Number of Subscriber)
______(Medi-Cal Number if Applicable)
______(Employer’s Name)
This waver will apply to all visit dates listed below: (Parent/Guardian Must Initial net to each date listed)
Date of Service: ______Initial here: ______81709 Dr. Carreon Blvd suite C- Indio CA 92201 Phone: (760) 342-4200 Fax: (760)-342-1600
REQUEST / REFUSAL FOR INTERPRETER SERVICES SOLICITUD O RECHAZO DE SERVICIOS DE UN INTÉRPRETE
□ YES, I REQUEST INTERPRETER SERVICES IN THE FOLLOWING LANGUAGE: ______
SI, NECESITO EL SERVICIO DE UN INTÉRPRETE EN EL SIGUIENTE IDIOMA: ______
□ I PREFER TO USE MY FAMILY OR A FRIEND AS AN INTERPRETER.
YO PREFIERO QUE MI FAMILIA O UN AMIGO/AMIGA SEA MI INTERPRETE.
□ NO, I DO NOT REQUIRE INTERPRETER SERVICES.
NO NECESITO LOS SERVICIOS DE UN INTERPRETE.
______PATIENT’S SIGNATURE / FIRMA DEL PACIENTE DATE / FECHA REQUEST TO PREPARE OR MAIL COPY OF MEDICAL RECORDS.
Release From: ______
Phone: ______
Fax: ______MY FAMILY CLINIC 81-709 Dr. Carreon Blvd. Ste. C-5 Indio, CA 92201 Phone: (760)342-4200 Fax: (760)342-1600
Name of patient: ______D.O.B. ____/____/______
Address: ______
I do not want my Medical Records Faxed/Hold for Pick Up.
Labs from: ______
Radiology report from: ______Medical Records: ALL M.R. (WCE & IMM. RECORDS Other: ______Please indicate your action so that we may inform the patient: If you are not able to MAIL the records please prepare for personal pick up.
WILL MAIL WILL HOLD FOR PATIENT PICK UP
FAX CONTINUATION OF CARE
_____/____/______DATE SIGNATURE